Physiotherapists can play an important role in palliative care by helping patients maintain mobility and independence even in advanced stages of illness. Key challenges include balancing patient wishes for activity with safety, and ensuring clear communication between professionals so rehabilitative care offers hope while respecting a terminal prognosis. Overall, physiotherapists should continue providing rehabilitative support to help patients live as fully as possible until the end of life.
Transitions: How can we help?
Wendy Duggleby
Persons receiving palliative care services and their families experience multiple, complex and concurrent significant changes which impact their hope and quality of life. This presentation will focus on the findings from several research studies on transitions and quality of life. An online “Changes Toolkit” developed for persons receiving palliative care and their families will also be presented.
Transitions: How can we help?
Wendy Duggleby
Persons receiving palliative care services and their families experience multiple, complex and concurrent significant changes which impact their hope and quality of life. This presentation will focus on the findings from several research studies on transitions and quality of life. An online “Changes Toolkit” developed for persons receiving palliative care and their families will also be presented.
How do we deliver on palliative care aspirations at the end of life in the acute setting?
Jean Clark, Karen Sheward, Joy Percy, Celine Collins, Simon Allan
Syringe driver medications: A study of combinations and clinical stability
Derryn Gargiulo, Jeff Harriso, Emma Griffiths, Bruce Foggo, Lauren Doherty, Sana Khan, Kate Kilpatrick, Guangda Ma, Caitlin Renouf, Susan Wilson
Whanau and personalising end-of-life care: Translating research for practice
Lesley Batten, Maureen Holdaway, Marian Bland, Jean Clark, Simon Allan, Bridget Marshall, Delwyn Te Oka, Clare Randall
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Transitions: How can we help?
Wendy Duggleby
Persons receiving palliative care services and their families experience multiple, complex and concurrent significant changes which impact their hope and quality of life. This presentation will focus on the findings from several research studies on transitions and quality of life. An online “Changes Toolkit” developed for persons receiving palliative care and their families will also be presented.
Transitions: How can we help?
Wendy Duggleby
Persons receiving palliative care services and their families experience multiple, complex and concurrent significant changes which impact their hope and quality of life. This presentation will focus on the findings from several research studies on transitions and quality of life. An online “Changes Toolkit” developed for persons receiving palliative care and their families will also be presented.
How do we deliver on palliative care aspirations at the end of life in the acute setting?
Jean Clark, Karen Sheward, Joy Percy, Celine Collins, Simon Allan
Syringe driver medications: A study of combinations and clinical stability
Derryn Gargiulo, Jeff Harriso, Emma Griffiths, Bruce Foggo, Lauren Doherty, Sana Khan, Kate Kilpatrick, Guangda Ma, Caitlin Renouf, Susan Wilson
Whanau and personalising end-of-life care: Translating research for practice
Lesley Batten, Maureen Holdaway, Marian Bland, Jean Clark, Simon Allan, Bridget Marshall, Delwyn Te Oka, Clare Randall
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
4. The big picture vs the moment
Rapid response
Living rather than dying
5.
6. Fear of being a burden to
others
Rehabilitative approach offers
hope
7.
8. Tension between client wishes and
care and safety
Coordination and Communication
between professionals is vital
9.
10. Rehab is seldom offered with a
terminal diagnosis
But there is still a life to be lived
11. To conclude …
Physiotherapists have a significant role to
play in the advanced stages of Palliative
Care
Editor's Notes
.Introduction
Hi everyone. I’m Pippa Grant. I work at Hospice North Shore and have worked there for the past 6 years. As far as I’m aware I belong to an exclusive club of three – physiotherapists employed by Hospices in NZ. Although I have more than 30 years’ experience as a neurological physio and treated people living with a terminal illness I must confess I only had a vague awareness of the field of Palliative care. l vividly remember the look on the friend who told me about the jobs face when I said “but what would a physio do at a hospice?” Now I can assure you I know, and have more than plenty to do. This brings me to the key message of this presentation: (pause) physiotherapy can play an important role for symptom management even in the advanced stages of Palliative Care.
With permission, I have chosen four patient stories as typical cases of my role. These cases will support my argument that our club of three expand. In my view/vision all hospices in New Zealand will employ physios as a matter of course.
My first case story is about the Symptom management of Pain
At 47, Kate was diagnosed with metastatic sigmoid colon cancer which spread to the lungs, liver and ovaries in spite of several cycles of chemo and other therapies.
At about 2 years she developed general joint pain and muscle spasms, particularly in her neck and shoulders. Pain significantly affected her mobility and quality of life. She was having difficulty sleeping, getting out of bed, dressing, showering and walking. She started taking brufen but stopped as she developed severe gastritis.
She was admitted to Auckland City Hospital and felt she “hit rock bottom”. An Xray of her cervical spine was normal. The pain did not respond to prednisone and she was discharged after a few days on morphine with a referral to hospice for help with pain issues.
The Community Palliative Care nurse asked me help with Kate’s joint pain and got myself and our Palliative Care specialist to see her urgently.
The specialist thought that Kates joint pains might be caused by a paraneoplastic syndrome – she ordered blood tests and adjusted her pain meds.
Early the next week I saw Kate at home. She had visited a doctor that day and had acupuncture. I was immediately concerned as she was in constant severe pain. She had no active shoulder movement and the humeral head was slightly subluxed. She had a complete rotator cuff tear but no history of trauma.
I explained I might be able to help with the pain but the problem wouldn’t improve without surgery, which at that stage wouldn’t be a priority.
I treated her with trigger point therapy, soft tissue work including “frictions” to rotator cuff tendons, and kinesiotaped the shoulder for pain relief and support.
Her husband was amazed she would even let me touch her shoulder. He gave me a bit of a fright when he told me he was a trained radiographer and asked what anatomical structure I was working on.
I also advised them why a sling would be of limited use and why taping was better referring them to youtube for taping techniques. I suggested a steroid injection might help and rang the GP who was able to visit and give her one the next day.
A couple of days later, Kate’s husband asking me to visit urgently as she had experienced good short-term relief from my treatment. He had tried the taping but didn’t think it had worked. When I got there, Kate was distressed. She was weak, shaky and continuously having to brace herself and breathe through the pain. She described it as more than 10/10 and was needing several extra doses of morphine for breakthrough pain. Her husband and I convinced her to agree to be admitted to our inpatient unit for symptom management and particularly further investigation of the pain
A CT scan the next day showed a large destructive osseous lesion in the left glenoid and the day after Kate had a single fraction of radiotherapy to this.
She was started dexamethasone and also given fentanyl spray for incident pain which she used before our daily therapy sessions.
After 2 weeks she went home. Her husband reported that her pain was much better so she didn’t need me to visit. I saw Kate one more time for another issue and she died peacefully a few weeks later.
This story illustrates that although in the big picture physios can’t do much, in the moment we can. Being part of the hospice team means that with a rapidly changing clinical picture such as this I can act quickly and I have direct access to a responsive team. Kate was happy and grateful to accept help with her pain issues but very reluctant to accept help she perceived as “hospice” such as a walker or hospital bed. She was in living rather than dying mode right to the end and was happy when I could genuinely say that she was looking better than on my previous visit.
This story is around the Symptom management of breathlessness
At 81 and suffering from end-stage COPD, Bob went through the added trauma of seeing his home destroyed in the Christchurch earthquake. He was forced to move to his daughter’s place in Auckland, leaving behind his beloved wife of 30 years.
He had major problems with anxiety and breathlessness, often waking at night gasping, coughing and choking. Bob’s daughter was more than happy to be involved in his care but he worried about being a burden.
Bob had discussed death and dying with his respiratory physician and established he no longer wanted any active treatment for his condition. So we had an ambulance letter and medications put in place so paramedics, if called, could provide symptom relief and if necessary admit him to hospice rather than hospital.
My involvement included building on and practising a step-by-step plan for times when he was panicky and breathless. On waking, he immediately took midazolam spray, morphine elixir if he was having coughing spasms, and his broncho-dilator via the spacer. He then sat in a lean-forward position on a couch beside the bed and turned a portable fan on his face. The next step was to try to slow his breathing down using breathing and relaxation techniques.
If his daughter was awake, she would coach him through these steps and repeat if necessary.
When Bob felt relatively well, we were able to adopt a more rehabilitative approach. We would work on breathing, relaxation, visualisation and mindfulness techniques some of which were on CD. I also gave him a simple exercise programme, which included walking with his walker and pacing himself through his activities of daily living. We provided him with an oxygen concentrator, which he used with activity, and a nebuliser.
When he was less well such as the time I had a call from the GP practice nurse to say he was “drowning in his secretions”, I did traditional chest physio techniques, such as postural drainage in alternate side lying, vibes, percussion and soft tissue work to the accessory muscles of respiration, and mobilising the chest wall.
Like many of the patients I treat suffering breathlessness, Bob reported feeling much better after this treatment.
After six months, a private hospital place became available in Christchurch and Bob was happily reunited with his wife.
Fear of being a burden on others has ben reported to be a more commonly cited reason for requesting euthanasia than uncontrolled pain. A rehabilitative approach can help a person feel they are helping themselves. Evidence from ex interventions with COPD patients has shown improved quality of life and participation, decreased breathlessness, depression, anxiety and hospital admissions .These improvements are significant regardless of disease severity.
The next story relates to Motor Neurone disease and the image I have chosen is of the book Tuesdays with Morrie which, to those of you not familiar with it, is a wonderful account of one man’s journey of living with MND
Anthony was diagnosed with pseudobulbar MND in March.
I first met him in December when he started having falls. On the Oxford scale, all Anthony’s muscles were a 2 – he could not contract them against gravity. He was rapidly becoming weaker but still fiercely trying to maintain his independence. He was unable to talk – he communicated via an ipad. He had a PEG but was still eating and occasionally choking.
He worked full-time, commuting to the city on the ferry and was still driving. I strongly recommended he use a walker but it would take many more falls, black eyes and bruises for him to start using one.
I taught Anthony strategies to get up after a fall but even then he needed some assistance. His son – a student - was around but Anthony didn’t want him seeing him lying on the ground.
Their house was a nightmare for wheelchair access and the community OT and I made two long visits to set up appropriate aids and equipment.
When Anthony finally did give up work, Taikura Trust were able to provide a carer. Together we worked to solve moving and handling challenges as they arose. Anthony wouldn’t consider moving to a more accessible house because, as his wife said, he expected to live for at least another 10 years.
We had regular monthly meetings at our Hospice for all health professionals involved in treating MND patients in WDHB, so we organised a case conference for Anthony to decide with the family how we could all best support them and co-ordinate his care. It was a huge meeting. Thirteen health professionals attended and all Anthony’s family – his wife, children, brothers and his mother, who, 30 years ago, had nursed her husband through the same disease with little support and not even knowing it was MND!
As Anthony got weaker he became confined to his house in a power chair with a hoist for transfers. Mobility, safety and access became less of a problem than carer exhaustion and respiratory issues - particularly managing secretions. His excess saliva and drooling was helped significantly with scopaderm patches but he had thick stringy mucus that built up through the day and extreme difficulty clearing this at night.
I had many conversations and email exchanges with the specialist, speech language therapist and community physios about how to manage the secretions. We tried breathing techniques such as breath stacking, postural drainage with vibes and percussion, assisted coughing using mucolytic agents such as Robotussin Plus through the PEG and a nebuliser.
Right to the end, Anthony had clear ideas of what he wanted which was sometimes hard on the carers. For example, he insisted on wearing his tight jeans which made dressing and toileting that much more difficult. And when he was finally persuaded to come into our inpatient unit for urgent respite care because his wife was at her wit’s end he only stayed for a couple of days before insisting he go home. He died relatively unexpectedly soon after.
In cases like these, where a person is physically and probably cognitively declining, there can be tension between their wishes and what is easier and safest for them, their carers and those around them. Anthony was driving, working, walking and eating long after it was safe for him to do so. Co-ordination of care and consistent communication are both crucial and in cases of rapid physical decline such as this physiotherapists can play a key role.
My final case which illustrates the bulk of my work and is probably what physio is most associated with is about Mobility
This is Sally
Sally was referred to me by a physio at North Shore Hospital. She had been an inpatient for a course of radiotherapy for a pelvic mass in the right sacroiliac area. Six months earlier she had developed right hip pain. Her physio eventually sent her to an orthopaedic surgeon who diagnosed metastatic melanoma.
On my initial visit, Sally was in a hospital bed. Her right leg was swollen and painful. She was experiencing 10/10 pain radiating down her thigh on mobilising and 2/10 pain at rest. I gave her a lymphatic massage for the oedema and active assisted bed exercises.
I checked her equipment and advised on the home environment. Over the next month I visited weekly. I kinesiotaped her leg but as Sally wasn’t sure if this had helped, I ordered her a light compression stocking instead.
She was soon able to walk to the living room but needed close supervision. She was dizzy on standing, her leg was painful and weak and she had a marked lopsided gait. Once she could tolerate standing, we started working on the exercises the hospital physio had given her.
The pain and swelling improved quite quickly but she still experienced stiffness and heaviness in the right leg.
Sally was fortunate to have a carer happy to learn massage techniques from me and to help her with daily exercises .They developed a great routine and she could proudly show me how she was able to open her ranch slider and garden gate, lift her walker in and out of the house and walk up and down her sloped driveway several times at a good pace, safely and independently. ( stop video)
I discharged her from physio but told her she could contact me at any time.
Sally is profoundly deaf and lived for years with her great friend Mary, who was also deaf. When I first started seeing Sally, Mary was her mainstay but sadly, Mary herself became unwell and was also on the hospice programme, dying within a few months.
However, on a happier note, the carer and her husband moved in with Sally, which meant she could stay in her own home. Now, more than 2 years down the track Sally is leading a relatively independent life - she is often out, walks without a walking aid and is even back driving.
Play second segment of video
Sally’s diagnosis could easily have meant that she was not offered physiotherapy treatment or follow up. Because of my role with the hospice she was referred to me. As a consequence of our work together Sally’s mobility improved significantly. This has made a huge difference to the quality of life she has enjoyed for the past few years which no one expected her to live.
To conclude, these stories are just a snapshot of a day in the life of a palliative physio, four stories from many I could have related.
My experience has been that patients are very keen to see a physio. They desperately want to maintain their independence, make choices, be active and participate. They let us in where they might not let others, perhaps because they see us as a symbol of hope. We help them to believe that they are not giving in and doing their best.
Physios are trained to assess and treat respiratory, neurological and musculo-skeletal conditions and many palliative patients end up having issues in all three of these areas. It is hard work psychologically, but when we just focus on “making each day the best day possible” and what we can do in the now, the rewards of making a difference are huge.
We can’t fix everything or, sometimes, even anything, but we can always do something. That is why physio should be an essential part of palliative care.